Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Saturday, January 29, 2011

The Eroding Physician Brand

It came as a Twitter 'follow' this morning from '@coldfeet65,' a self-proclaimed 'Nurse Practitioner Hospitalist.'

I had never heard this term before.

Does it mean a Nurse Practitioner who cares for Hospitalists? Or is it a Hospitalist who is a Nurse Practitioner? Or maybe it's a Nurse Practitioner who helps Hospitalists? (Honestly, I think I know which one she means, but you get my point.)

Perhaps this is a prescient glimpse to health care of the future, where our more typical nurse and doctor labels are supplanted by more and more monikers that serve to confuse, rather than clarify, each of our roles in health care delivery. As specialists in cardiology, we've seen a similar trend with cardiology hospitalists.

But we should be clear what this means to the patients and doctors going forward.

No doubt most people in America still expect to see a doctor when they come to the hospital. Increasingly, it appears that might not be the case. Your doctor might be a robot while a nurse (aka, nurse practitioner) will be the one providing the hands-on care in the inpatient setting. Is that a good thing?

Honestly, I'm not sure.

No one argues that the costs in health care need to be cut. No doubt the Central Authority has deemed that doctor salaries will be a big part of that effort. Already, 20 states have cut physician Medicaid payments for fiscal year 2010 and, given the current economic pressure on our states both now and after they start feeling the financial impact of the "Affordable" Care Act in 2019, this trend is not likely to improve anytime soon. As a result, we are seeing that the world is full of "creative solutions" to our health care access crisis and the evolution to Nurse Practitioner Hospitalists might be one of these.

But what are Doctors of Medicine becoming as a result? Are our current cohort of primary care doctors becoming little more than nurse managers and fact-checkers of mandated protocols, treatment guidelines, and care directives?

Hopefully not.

But increasingly it appears that those without a hands-on, invasive skills in medicine (like surgery) are being marginalized in the health care models going forward. This trend now appears to even be affecting the much-heralded inpatient hospitalist care model as the doctor shortage intensifies. Consequently, the image of "doctor" as we knew it is changing, not only for what patients can expect to encounter when they come to a hospital, but for the type (and caliber) of the doctor we attract to our profession going forward.

17 comments:

Anonymous
said...

Thanks for the mention, Dr. Wes. My title says "hospitalist" because that's what I do. Just as when I worked in primary care, I was a primary care practitioner. I'll try not to be insulted, and I'm sure we'd be great friends if you got to know me. As a nurse practitioner working in acute care, I often find it interesting that this is a new concept to some. NPs and PAs have been providing healthcare in the acute care setting for several years now especially in larger cities where it may be difficult to attract "real doctors." I introduce myself as a "nurse practitioner" to all of my patients and they are also seen by a physician in most cases. The physician I currently work with is the medical director of our program, and after given the choice to start up this new program with 3 docs or 2 docs and 2 NPs, he chose to bring me and my co-worker along because he knew our work ethic and our abilities to care for patients. I will be the first to admit that not all NPs are trained for this work, but the several years of emergency department experience I had, as well as critical care background has prepared me quite well for the acuity of patients I am seeing.

I didn't go looking for this job, it found me, and mostly it was due to relationships I have built with local physicians and reputation I have for providing competent and quality care. The patient is never left in the dark about who is seeing them, and they know that we all work as a team. In the area I'm from, the term "doctor" simply means someone who takes care of another when they are sick. There are very few MDs left in our area, and recruiting is near impossible since we are at least an hour from even a Starbucks.

By the way, most of the time when I tell a patient I'm a nurse practitioner they say "oh, my family doctor is a nurse practitioner, too!"

You are correct, and most physicians in the hospitalists programs are primary care trained and recruited to their local facilities; there are some programs now specifically for hospitalist NPs and PAs. And clearly, I am a nurse first and very proud of that fact, since research shows outcomes to be superior with NPs providing care, even in some acute care areas. We do not work strictly from protocols as your blog insinuates, we go through the same thought processes as a "brand name doctor." So let's be clear, when and if I finish my Doctor of Nursing Practice degree, I will be a "doctor" too. That's another battle for another day and another NP to fight, not me. I love my "real doctor" co-workers, and my local cardiologists and I are great friends. Who better to get your referrals (aka bread and butter) from?

I have a friend who is a NP working in a similar capacity at a large California hospital. The program she works for employs NP Hospitalists to ensure that their service has coverage when residents have to leave to comply with work hour regulations.

we have pa and np hospitalists at our hospital. our area is buckling under increasing workload and not enough docs.it's kind of a desperation maneuver since we can't seem to find enough docs and at the same time, in commenting specifically to our hospital situation, the np and pa hospitalists and er extenders may alleviate their respective departments, but at the cost of making life busier for the consulting departments. depending on how hungry you are for consults, that may or may not be a good thing.most of the docs in the area have more consults than they know what to do with, but also can't find doctors to hire. something has to give sooner or later.

There is another way to look at it instead of eroding physician brand. What if these extenders are actually freeing up docs to use their higher level skills instead? I highly recommend "Transforming Health Care" by Charles Kenney regarding Virginia Mason's use of the Lean system to literally transform how it delivers health care (it is VERY eye opening). An excerpt:"A key to making this new approach work...is to get the skill-task alignment right. Under the old system.....[regarding back pain]highly paid surgeons seeing patients with uncomplicated back pain. The surgeons cost a great deal of money - 4 times the cost of a physical therapist - but added no value for the uncomplicated conditions that afflict most patients." You'd have to read it to see how they ruled out complicated conditions (too long), but the point is to use our skills where they are needed, and not where they are not needed. This is not an erosion but, in truth, an elevation, if used correctly.The trick is to be aligned with an organization that can do that; not so easy......

I've always thought that med school was probably closer in structure to trade school than college.

It's really not that hard to imagine that you could strip out all the BS from pre-med and the pre-clinical years and use that to produce a serviceable doctor. How much of your organic chemistry do you really use anymore after all?

Maybe what were getting with the new NP model is an army of caregivers in which the education is stripped down to only what's really necessary to provide patient care. We all know that 99% of what's necessary to take care of patients is learned "on the job."

I'm not sure that's such a bad thing, but it certainly is disruptive for us doctors. I agree that most of the NPs I've worked with are highly capable and hard working. The care they deliver commonly equals or exceeds those of their doctor colleagues. Often the only thing that separates them from us is the level of experience (as most in my experience are relatively young). With time, they'll probably be just as good at making the tough call as the MDs.

Around here, you can see doctors essentially giving away their jobs to physician extenders. Most of the new patient assessments and call coverage is now done by NPs in our institution. Doctors more and more are transitioning into an oversight role. The doctors may just be making themselves unnecessary, and I'm not sure they realize that.

I share your comfort that my job as an electrophysiologist is very technical and hands-on. It's going to be tougher to replace me with cheap labor than it will be with some of my colleagues.

Wes, This topic interests me for many of the reasons you mention - it bears on what doctors do, health care costs, the future of medicine...

In my role as a patient, I've thought about this a lot. In the future if I'm ever hospitalized, it's unlikely my usual doctors will be there (except perhaps as a courtesy, on occasion) and that thought is terrifying. The "system" doesn't know and can't calculate the value of trust and a long-established patient-doctor relationship for someone who's very sick and in the hospital.

I bet you learn dozens of new terms every year in a practice that is so linked with technology. So what's so hard to ask the person about his title? With time, I hope you will be encouraged by the professional evolutions of your colleagues. It would seem to answer our concerns about providing access to health care to more people. And I'm surprised you dismiss "robots" - I've seen a number of robot-like gadgets (is it still a gadget if it costs thousands of dollars?)featured in this blog. I wish you would be as excited by the addition of more skilled manpower as you are by mechanical power.

Your post title, The Eroding Physician Brand", reminds me of the many marketing meetings I've attended. Our solution for protecting our brand was to keep others off the shelves, enforce trademarks, limit production and keep our prices high. That, sir, is one lousy way to run a health care system.

Okay. We're going to make you king. Now go ahead and repeal ACA. Now the year is 2015. Let me know how much the cost of health care has declined vis a vis 2010 and how many uninsured we have. Finally where do physicians fall in overall U.S. income rankings 2010 vs 2015?

"Eroding the Physician Brand", the title alone lets many know how under educated you are in terms of Nurse Practitioners. Did you wait and research the requirements of becoming an NP before typing our your own eroded opinion? I can't help but wonder how many NP's have refereed patients to your care?

At the end of the day it comes down to an unfortunate miss education. Nurse Practitioners have and will continue to fill a basic need in health care. Often qualitative studies have shown our effective care not only stops congestion in emergency departments, but also decreases long term health care costs due to our ability to have great impacts on lifestyle modification. It might be time to educate yourself and work in a collegial manor with NP's in your area.

In an era where patients want and deserve transparency, there's a need for those of us doctors who went to medical school to point out that there are certain types of health care providers out there that are using titles usually reserved for people who have attended medical school (and residency training) that have not undergone a similar training requirement themselves.

That just may (or may not) make a difference to patients - but at least they can then make an informed decision. Nurse practitioner hospitalists (or other 'nurse-doctors') at least have an obligation to their patients at the outset to come clean on this important distinction.

Patients are not the ones confused. I make it clear to them who I am and what I do ( I know I'm repeating myself but I don't think you heard me the first time). So do you have any NPs in your cardiology practice? Because the ones I know are referred to as cardiology NPs, since that's the area they work in, as are orthopedic PAs. I'm sorry if we step on your feelings, and if we somehow make you feel your degree is less. I don't see it that way at all, but I do think some think more highly of themselves than they should. I got into this to help people, not for the money or the power as someone suggested. There is not much of either of those unless one is a specialist like yourself.

This is not to mention, too, all the premedical and medical students who go around blogging and tweeting and forum-posting with "Dr. _____" or "_____, MD" monikers. I've started assuming that anyone with "Dr." in their username is probably...not one. Not yet, at least, and I doubt they'd walk around their campuses or hospitals introducing themselves as such. Why do we tolerate it on the internet, then?

"NPs for growing hospitalist team". Northshore, Advocate, etc. It's common. You forget The Corporation is not as interested in medicine as it is in money. Corporate has decided you guys are too finicky and too expensive so it's time to cut back. You all should have stayed out on your own at all costs. See what happens when you work for The Man? It's not fun being devalued.

As I was searching for material to include in our Nurses' Week activities, I came across this blog. This year's theme is "in Nurses We Trust." I was searching for something to support the idea of the importance of trust between the physician and nurse.

I am disappointed to see another physician who appears to feel threatened by someone with different letters behind their name. Medicine and Nursing are not the same. an MD and an NP should not be approaching health care from the same perspective, except for the basics (pt autonomy, do no harm, etc)

When will physicians start to recognize the value of appreciating other practicioners' skills and contributions instead of being so focused on protecting some nebulous aire of authority? Please.

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.